Circumcision and HIV

Circumcision and HIV: Harm Outweighs "Benefit"

Two American-sponsored studies in Africa claim that adult male circumcision significantly reduces the risk of acquiring HIV.(1) Researchers then take the leap of recommending adult male circumcision as an HIV prevention strategy. Publishing such a report in the United States appears to support the American cultural practice of circumcision. Such judgments are dangerous.

The Kenya report spotlighted a 53% reduction of HIV acquisition in circumcised men relative to genitally intact men. However, only 47 of the 1,391 (one in 30) genitally intact men in the study contracted HIV, compared to 22 of the 1,393 (one in 63) circumcised men. These figures showed that about 56 circumcisions were needed to prevent one HIV infection, and 55 out of 56 circumcised men received no benefit. In the Uganda study, investigators estimated that 67 circumcisions were needed to prevent one HIV infection while the rate of moderate and severe circumcision complications was about 4%. Therefore, the chance of such a complication was more than 2.5 times greater than the chance of protection from an HIV infection, not including complications that would appear years later. In addition, an association between circumcision and HIV infection does not prove a cause and effect relationship. There could be confounding variables. For example, circumcision changes sexual behavior. The studies failed to avoid selection bias and expectation bias. The studies were stopped early, and duration of the trials were short. No long-term followup can be done. The effects of commercial sex workers, female circumcision, genital ulcers, unsafe medical practices, nonsexual HIV infection, and condom use were not included. Furthermore, the HIV status of the female partners in the studies was not determined. We recommend using the common sense test: if any other healthy body part (e.g., finger, toe, ear) were recommended for removal to prevent an unlikely disease, would American observers respond with equal approval?

The studies do not account for cultural bias on the part of researchers.(2) The Cochrane Collaboration is an international independent source of reliable evidence-based reviews of healthcare information. It reports, "Circumcision practices are largely culturally determined and as a result there are strong beliefs and opinions surrounding its practice. It is important to acknowledge that researchers’ personal biases and the dominant circumcision practices of their respective countries may influence their interpretation of findings.”(3) The lead researchers of the African studies are known American circumcision advocates.

Claims that circumcision reduces the risk of acquiring HIV infection have been made for 20 years. Other studies have found no significant effect of circumcision status on HIV acquisition.(4) Publication bias in favor of positive results makes it more difficult to bring attention to studies with negative outcomes. The fact is that the United States has a high circumcision rate and the highest prevalence of HIV infection in the developed world.(5) Other countries have lower rates of HIV infection than the United States and do not practice circumcision. National medical organizations unanimously find no proven medical benefit for circumcision and do not recommend it.(6) Furthermore, in a previous study published on the effectiveness of condoms in preventing HIV acquisition, heterosexual couples that included an HIV-infected partner used condoms consistently in a total of about 15,000 instances of intercourse. None of the uninfected partners became infected.(7) That’s why the American Medical Association states that “behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as ‘protecting’ against such infections.”(8) Using or promoting unnecessary surgery when much less invasive, much less costly, and much more effective methods are available (e.g., condoms) raises ethical concerns. The cost of one circumcision in Africa can pay for 3500 condoms. The African study investigators also advise circumcision for treating phimosis (nonretractable foreskin) when other less invasive and less costly methods are available.(9) Furthermore, the studies recommend the use of condoms in addition to circumcision. Because of the superior effectiveness of condoms, circumcision adds little additional protection.

Unlike Africa, America circumcises males in infancy. The African adult studies cannot be applied to American infants because of the difference between the two groups. Because sexually transmitted diseases obviously cannot be transmitted until an individual engages in sexual activity, a male may make a decision to be circumcised when he is older without losing this claimed “benefit.” If you were an adult male and had the option of using a condom and getting virtually assured protection or having part of your penis cut off to get a one in 56 chance of protection, the choice is clear. Furthermore, by the time today’s newborn boys become sexually active, HIV vaccine may be available.

American circumcision studies have found dozens of “benefits,” from treating epilepsy and masturbation in the late 1800s to preventing sexually transmitted diseases today.(10) Though such claims generally do not withstand scrutiny by medical policy committees, their continued publication over the years has led to medical myths while raising questions about some researchers’ motives. American researchers tend to avoid studying or acknowledging the sexual and psychological harm associated with circumcision.(11) This pro-circumcision bias in American medicine reflects the pro-circumcision bias in American culture. The United States is the only country in the world that circumcises most (56%) of its male infants for non-religious reasons.(12) When Europeans learn about this, they think we’re crazy.

Knowledge of studies on circumcision harm is important to properly evaluating advisability. There is strong evidence that circumcision is overwhelmingly painful and traumatic.(13) Some infants do not cry because they go into shock. Infants exhibit behavioral changes after circumcision. Changes in pain response have been demonstrated at six months of age, evidence of lasting neurological effects and a symptom of post-traumatic stress disorder.(14) Anesthetics, if used, do not eliminate circumcision pain.(15)

The common American belief is that the foreskin has no value. That’s because most American circumcised men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft, equivalent to approximately twelve square inches on an adult.(16) Medical studies have shown that the foreskin protects the head of the penis, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialized nerves and results in thickening and progressive desensitization of the outer layer of the tip of the penis, particularly in older men.(17) In a survey of men who were circumcised after they became sexually active, there was a reported decrease in sexual enjoyment after circumcision.(18) One described it as like seeing in black and white compared to seeing in color. If you have less, you feel less. Circumcision removes the five most sensitive parts of the penis.(19) (For this reason, many circumcised men are reluctant to use condoms because it contributes to further decreased sensation. Reduced condom usage adversely affects the HIV infection rate.) In a survey of those with comparative sexual experience, women preferred the natural penis over the circumcised penis by 6 to 1.(20)

Surveys of circumcised men and clinical reports show that when men recognize their loss due to circumcision and experience associated decreased sexual sensitivity, they report wide-ranging psychological consequences.(21) Most circumcised men seem satisfied because they may not understand what circumcision is and the benefits of the foreskin, they may not be aware of certain feelings and their connection to circumcision, or they may be afraid of disclosing these feelings.(22)

For American society, circumcision is a solution in search of a problem, a social custom disguised as a medical issue. Beware of culturally-biased studies on circumcision posing as science, and take your whole baby home.

(See About Bias and Circumcision Policy: A Psychosocial Perspective.)

NOTES

1. Press release from National Institutes of Health, 12/13/06.
2. Goldman, R., “Circumcision Policy: A Psychosocial Perspective.” Paediatrics and Child Health 9 (2004): 630-633.
3. Siegfried, N., Muller, M., Volmink, J., Deeks, J., Egger, M., Low, N., Weiss, H., Walker, S., Williamson, P. "Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men," (Cochrane Review) In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.
4. Carael, M., Van de Perre, P., Lepag, P., et al., “Human Immunodeficiency Virus Transmission Among Heterosexual Couples in Central Africa,” AIDS 2 (1988): 201-205; Barongo, L., Borgdorff M., Mosha, F., Nicoll, A., Grosskurth, H., et al. “The Epidemiology of HIV-1 Infection in Urban Areas, Roadside Settlements and Rural Villages in Mwanza Region, Tanzania,” AIDS 6 (1992):1521-1528; Chao, A., Bulterys, M., Musanganire, F., et al. “Risk Factors Associated with Prevalent HIV-1 Infection Among Pregnant Women in Rwanda,” National University of Rwanda-Johns Hopkins University AIDS Research Team, International Journal of Epidemiology 23 (1994):371-380; Grosskurth, H., Mosha, F., Todd, J., et al. “A Community Trial of the Impact of Improved Sexually Transmitted Disease Treatment on the HIV Epidemic in Rural Tanzania: 2. Baseline Survey Results,” AIDS 9 (1995): 927-934; Changedia, S., Gilada, I. “Role of Male Circumcision in HIV Transmission Insignificant in Conjugal Relationship (abstract no. ThPeC7420),” Presented at the Fourteenth International AIDS Conference, Barcelona, Spain, July 7-12, 2002; Thomas, A., Bakhireva, L., Brodine, S., Shaffer, R. “Prevalence of Male Circumcision and Its Association with HIV and Sexually Transmitted Infections in a U.S. Navy Population,” abstract no. TuPeC4861, Presented at the XV International AIDS Conference, Bangkok, Thailand, July 11-16, 2004.
5. Nicoll, A. “Routine Male Neonatal Circumcision and Risk of Infection with HIV-1 and Other Sexually Transmitted Diseases,” Arch Dis Child 77 (1997):194-5.
6. Medical organization statements at http://www.cirp.org/library/statements/.
7. De Vincenzi, I. “A Longitudinal Study of Human Immunodeficiency Virus Transmission by Heterosexual Partners,” New England Journal of Medicine 331 (1994): 341-6.
8. Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision, Chicago: American Medical Association, 2000.
9. Chu C, Chen K, Diau G. "Topical Steroid Treatment of Phimosis in Boys," Journal of Urology 162 (1999) : 861-3.
10. Gollaher, D. Circumcision: A History of the World’s Most Controversial Surgery, New York: Basic Books, 2000.
11. Goldman, R., “Circumcision Policy: A Psychosocial Perspective.” Paediatrics and Child Health 9 (2004): 630-633; Boyle, G., Goldman, R., Svoboda, J., Fernandez, E. “Male Circumcision: Pain, Trauma and Psychosexual Sequelae,” Journal of Health Psychology 7 (2002):329-343.
12. National Center for Health Statistics, 6525 Belcrest Rd., Hyattville, MD 20782. Rate is for 2003.
13. Ryan, C. & Finer, N. “Changing Attitudes and Practices Regarding Local Analgesia for Newborn Circumcision,” Pediatrics 94 (1994): 232; Howard, C., Howard, F., & Weitzman, M. “Acetaminophen Analgesis in Neonatal Circumcision: The Effect on Pain,” Pediatrics 93 (1994): 645; Benini, F. et al., “Topical Anesthesia During Circumcision in Newborn Infants,” Journal of the American Medical Association 270 (1993): 850-3; Gunnar, M. et al., “Coping with Aversive Stimulation in the Neonatal Period: Quiet Sleep and Plasma Cortisol Levels During Recovery from Circumcision,” Child Development 56 (1985): 824-34; Williamson, P. & Williamson, M., “Physiologic Stress Reduction by a Local Anesthetic during Newborn Circumcision,” Pediatrics 71 (1983): 40; Stang, H. et al., “Local Anesthesia for Neonatal Circumcision,” Journal of the American Medical Association 259 (1988): 1510; Lander, J., Brady-Fryer, B., Metcalfe, J., Nazarali, S., and Muttitt, S. "Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision," Journal of the American Medical Association 278 (1997): 2157-62; Romberg, R. Circumcision: The Painful Dilemma. South Hadley, MA: Bergin & Garvey, 1985.
14. Taddio, A., Katz, J., Ilersich, A., and Koren, G. "Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination," The Lancet 349 (1997): 599-603.
15. Lander, J., Brady-Fryer, B., Metcalfe, J., Nazarali, S., and Muttitt, S. "Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision," Journal of the American Medical Association 278 (1997): 2157-62.
16. Taylor, J., Lockwood, A., & Taylor, A., “The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision,” British Journal of Urology 77 (1996): 294.
17. Taylor, J., Lockwood, A., and Taylor, A. "The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision." British Journal of Urology 77 (1996): 291-95; Ritter, T., and Denniston, G. Say No to Circumcision. Aptos, CA: Hourglass, 1996; Money, J., and Davison, J. "Adult Penile Circumcision: Its Erotosexual and Cosmetic Sequelae," Journal of Sex Research 19 (1983): 289-92; Cold, C., and Taylor, J. "The Prepuce." BJU International 83 (suppl. 1) (1999): 34-44; O'Hara, K., and O'Hara, J. "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," BJU International 83 (suppl. 1) (1999): 79-84; Hammond, T. "A Preliminary Poll of Men Circumcised in Infancy or Childhood," BJU International 83 (suppl. 1) (1999): 85-92; Rhinehart, J. "Neonatal Circumcision Reconsidered," Transactional Analysis Journal 29 (1999): 215-21; Goldman, R. Circumcision: The Hidden Trauma. Boston: Vanguard Publications, 1997.
18. Kim, D. & Pang, M. “The Effect of Male Circumcision on Sexuality,” BJU International (2007): in press.
19. Sorrells, M. et al. "Fine-Touch Pressure Thresholds in the Adult Penis," BJU International 99 (2007): 864-869.
20. O'Hara, K., and O'Hara, J. "The Effect of Male Circumcision on the Sexual Enjoyment of the Female Partner," BJU International 83 (suppl. 1) (1999): 79-84.
21. Hammond, T. "A Preliminary Poll of Men Circumcised in Infancy or Childhood," BJU International 83 (suppl. 1) (1999): 85-92; Rhinehart, J. "Neonatal Circumcision Reconsidered," Transactional Analysis Journal 29 (1999): 215-221.
22. Goldman, R. Circumcision: The Hidden Trauma. Boston: Vanguard Publications, 1997.